WomenFirst Membership Application

WomenFirst has the people and the resources dedicated to meeting your needs. Because we know your time is valuable, WomenFirst comes to your neighborhood with health and lifestyle seminars on almost every problem you face.

If you need information on topics like building self-esteem, stress management, menopause, PMS, heart disease, breast care, retirement - anything you'd like to know more about, a WomenFirst coordinator will personally work with you to get the help you need. That's what makes WomenFirst different.

WomenFirst members also receive discounts from local merchants and benefit from special invitations and discounted admission to workshops, seminars and health screenings.

A one-time $15 fee makes you a member of WomenFirst.
To help you meet all the challenges of your life;because you have better things to do with your time

For more information call 256-737-2600.

* Memberships are non-transferrable. Any and all benefits provided to WomenFirst members are subject to revisions, deletions or improvements as the case may be at any time and at the sole discretion of Cullman Regional Medical Center.

Please fill out the form below. You may pay your membership fee by credit card or by check. All information will be kept secure and confidential. For more information you may call our office during business hours at (256) 737-2600.

You may make payments to the CRMC WomenFirst using your credit card account number or checking account routing number in the fields below. All payments are via secure server.

Enter your information EXACTLY as it appears on your billing / statement; otherwise, your submission may result in a failed payment.

Please only click the SUBMIT button at the bottom of the form once. Clicking more than once may result in multiple payment transactions.

Thank you for allowing us to serve you.

Please provide information below as it is listed on your credit card.

* Required Fields

First Name: *

Last Name: *

Address: *

Address Continued:

City: *

State: *

Zip: *

Country: *

Email: *

Phone Number:

Amount: (Ex. 120.00)
*

Payment Type:

Credit Card Number: *

Expiration Date:

Card Security Code (CSC) *

Employer

Your Birthdate *

Membership Number (Soc. Sec. Number)

Are you:SingleMarried

If married, Husband's Name

Do you have children?YesNo

If yes, how old are your children?

Which WomenFirst program most applies to you now?TeensObstetricsWorking WomenRetiredMature Woman